Do we need to have stricter criteria for referrals? – Charlotte Gentry

  Posted by: Dental Design      20th April 2018

Referrals are, of course, hugely necessary. They enable patients to get specialised and appropriate care that may not be able to be provided in primary care. Working in a hospital means a lot of the patients I see in my speciality teaching are patients that have been referred. I’ve mentioned before that I find it odd how us as undergraduates are seeing cases that are too complex for qualified dentists to see; however, many of these patients actually present relatively simple cases that should be managed in-practice.

An appropriate referral

The biggest question is: what is an appropriate referral? Some are obvious – a suspected malignancy or more serious condition that has presented orally. However, I have seen many a referral that seems too simple to require secondary care. I’ve heard stories of molar endodontic cases being referred into the dental hospital. Of course, molar endodontics is a complex procedure and some may need specialist treatment. Yet, many of these are relatively ‘simple’ and could be managed in the primary care setting. The question with regards to these cases is – are they due to a lack of confidence/training in the procedure, or are they being referred because of financial reasons? Either way, something needs to be done to ensure that the people who really need the secondary care appointments are getting them.

Another area I have seen inappropriate referrals is in the oral medicine clinic. I’ve only had a few oral medicine clinics and we as a group see around six patients a session. Already there have been three cases of periodontal disease referred into these clinics. All of these referred patients had a complaint of ‘bleeding gums’.

Although there are other more serious, differential diagnoses for bleeding gingiva, such as acute leukaemia, these patients had no other symptoms that would indicate this and presented with deep probing depths. I think anyone reading this would agree that this referral is completely inappropriate and although we need to take into account differing levels of skill and abilities amongst dentists, this really is the basics of dentistry and this case should perhaps never have been referred.

Is there an answer?

So how can we filter out these inappropriate referrals? There is talk of everyone going over to an electronic referral system where by a criterion needs to be fulfilled in order for a referral to be accepted by a secondary care centre. This sounds like a good solution but the practicalities of it could be difficult. Ensuring it is introduced into all practices and making a criterion that will pick up on every concerning symptom may be tricky. It is important to ensure there are no loopholes in which patients, who may need complex care, can fall through. As well as this, loopholes in the system may mean that we still see inappropriate referrals for practitioners. Therefore, the system needs thorough planning in order to be effective.

There is no perfect solution and a completely perfect referral system most probably doesn’t exist. However, with an already tight NHS budget it is vital that it is being optimised and spent on the patients that really do need the secondary care.